Provider Demographics
NPI:1528818705
Name:BARNES, KIYONTRE TYQWAN
Entity type:Individual
Prefix:
First Name:KIYONTRE
Middle Name:TYQWAN
Last Name:BARNES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 STRATHMORE CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-8808
Mailing Address - Country:US
Mailing Address - Phone:843-635-1426
Mailing Address - Fax:
Practice Address - Street 1:6953 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-6710
Practice Address - Country:US
Practice Address - Phone:407-968-8356
Practice Address - Fax:407-264-6443
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-332315106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician